Sigmoid Diverticular Disease Yair Edden, MD Department of Surgery Shaare-Zedek Medical Center The Hebrew University School of Medicine Jerusalem, Israel

Nomenclature Diverticulum = sac-like protrusion of the colonic wall Diverticulosis = describes the presence of diverticuli Diverticulitis = inflammation of diverticuli

Nomenclature True Diverticulum = all layers of the GI wall (mucosa to serosa) e.g. Appendix, Meckel, Congenital False/Pseudo Diverticulum = Mucosa-submucosa herniates through the muscle layer (muscularis propria) and then is only covered by serosa e.g. Acquired pathology

Epidemiology- Sigmoid diverticulosis Before the 20th century, diverticular disease was rare Prevalence has increased over time 1907 First reported resection of complicated diverticulitis by Mayo 1925 5-10% 1969 35-50%

Epidemiology- Sigmoid divericulosis Increases with age: Age 40 <5% Age 60 30% Age 85 65% Younger patients are diagnosed frequently

Endoscopic appearance

Double contrast Barium enema

CT Scan

CT Scan

From out side…

Anatomic location of diverticuli varies with the geographic location “Westernized” nations have predominantly left sided diverticulosis 95% diverticuli are in sigmoid colon 35% can also have proximal diverticuli 4% have only right sided diverticuli

Anatomic location of diverticuli varies with the geographic location Asia and Africa diverticulosis in general is rare and usually right sided Prevalence < 0.2% 70% diverticuli in right colon in Japan

Pathophysiology Diverticuli develop in ‘weak’ regions of the colon. Specifically, local hernias develop where the vasa recta penetrate the bowel wall

Pathophysiology Law of Laplace: Pressure = K x Tension / Radius Sigmoid colon has the smallest diameter resulting in highest pressure zone

Pathophysiology Segmentation = motility process in which the segmental muscular contractions separate the lumen into chambers Segmentation  increased intraluminal pressure  mucosal herniation  Diverticulosis May explain why high fiber prevents diverticuli by creating a larger diameter colon and less vigorous segmentation

Pathophysiology

Lifestyle factors associated with diverticular disease Low fiber  diverticular disease Not absolutely proven in all studies but strongly suggested Western diet is low in fiber with high prevalence of diverticulosis In contrast, African diet is high in fiber with a low prevalence of diverticulosis

Lifestyle factors associated with diverticular disease Obesity associated with diverticulosis – particularly in men under the age of 40 Lack of physical activity

Lifestyle factors associated with diverticular disease Do patients need to avoid foods with seeds or nuts?

Lifestyle factors associated with diverticular disease NO!

In most cases diverticular disease is a-symptomatic

A-symptomatic diverticulosis Considered ‘a-symptomatic’ However, some patients will complain of cramping, bloating, irregular BMs, narrow caliber stools Confused with IBS Recent studies demonstrate motility abnormalities in patients with ‘a-symptomatic’ uncomplicated diverticulosis

Diverticulitis Diverticulitis = inflammation of diverticuli Most common complication of diverticulosis Occurs in 10-25% of patients with diverticulosis

Diverticulitis Subclinical inflammation to generalized peritonitis Micro or macroscopic perforation of the diverticulum Subclinical inflammation to generalized peritonitis Previously thought to be due to fecaliths causing increased diverticular pressure; this is really rare

Diverticulitis intraluminal pressure Inflammation Erosion of diverticular wall from increased intraluminal pressure Inflammation Focal necrosis Perforation Usually inflammation is mild and microperforation is walled off by peri-colonic fat and mesentery

Diagnosis of Diverticulitis Classic history: increasing, constant, LLQ abdominal pain over several days prior to presentation with fever Crescendo quality – each day is worse Constant – not colicky Fever occurs in 57-100% of cases

Diagnosis of Diverticulitis Previous episodes of similar pain Associated symptoms Nausea/vomiting 20-62% Constipation 50% Diarrhea 25-35% Urinary symptoms (dysuria, urgency, frequency) 10-15%

Diagnosis of Diverticulitis Diagnosis can be made with typical history and examination Radiographic confirmation (CT) is often… (100%) performed Rules out other causes of an acute abdomen Determines severity of the diverticulitis

CT Scan

CT Scan

Simple vs. Complicated Diverticulitis Complicated diverticulitis = Presence of macroperforation, obstruction, abscess or fistula Simple diverticulitis = Absence of the above complications

Simple vs. Complicated Diverticulitis Complicated diverticulitis = Presence of macroperforation, obstruction, abscess or fistula Simple diverticulitis = Absence of the above complications

Simple Diverticulitis Hospitalization !?

Simple Diverticulitis IV Antibiotics Bowel rest, clear liquids for 2-3 days Based on clinical findings advance diet (low residue) and PO antibiotics

Simple Diverticulitis After resolution of attack - high fiber diet with supplemental fiber

Simple Diverticulitis Follow-up: Colonoscopy in 4-6 weeks Purpose Exclude neoplasm Evaluate extent of the diverticulosis

Simple Diverticulitis Prognosis after resolution 30-40% of patients will remain asymptomatic 30-40% of patients will have episodic abdominal cramps without frank diverticulitis 20-30% of pts will have a second attack

Simple vs. Complicated Diverticulitis Complicated diverticulitis = Presence of macroperforation, obstruction, abscess or fistula Simple diverticulitis = Absence of the above complications

Complicated Diverticulitis Hinchey classification Pericolic abscess Distal abscess Purulent peritonitis Fecal peritonitis Hinchey EJ et al. Treatment of perforated diverticular disease of the colon. Adv Surg. 1978

Complicated Diverticulitis Hinchey classification Pericolic abscess Distal abscess CT guided drainage

Complicated Diverticulitis Hinchey classification 3. Purulent peritonitis 4. Fecal peritonitis Surgery

Complicated Diverticulitis Hartman’s Procedure

Complicated Diverticulitis Other clinical presentation Bleeding Stricture Fistula

Complicated Diverticulitis Other clinical presentation Bleeding

Complicated Diverticulitis

Complicated Diverticulitis

Complicated Diverticulitis Most only have symptoms of bloating and diarrhea but no significant abdominal pain Painless hematochezia Start – stop pattern; “water faucet” Diverticulitis rarely causes bleeding Right > Left

Complicated Diverticulitis Other clinical presentation Stricture

Complicated Diverticulitis Chronic inflammation Bloating Constipation

Complicated Diverticulitis Other clinical presentation Stricture Surgery

Complicated Diverticulitis Other clinical presentation Fistula

Complicated Diverticulitis Chronic inflammation Small Bowel Bladder Vagina (s/p Hysterectomy) Retro – peritoneum

Complicated Diverticulitis Other clinical presentation Fistula Surgery

Re-operative Surgery for Crohn’s Disease

What Will Be Your Approach? Open vs. Lap.?

Re-operative Surgery For Crohn’s Disease

Re-operative Surgery For Crohn’s Disease

Re-operative Surgery For Crohn’s Disease Sometimes it looks like this:

Re-operative Surgery For Crohn’s Disease

So, Why Bother? Less pain Shorter stay Less morbidity compared with open ?! Faster return to normal activity Immunologic & metabolic benefits Adhesion formation, reduced SBO Lower recurrence in Crohn’s ? Cosmesis

Anticipated Problems 1 Port of entry & pneumoperitoneum Adhesions & limited exposure Anatomical orientation due to previous resection / procedure

Anticipated Problems 2 Identification of pathology Potential Intra-operative complications (bleeding, enterotomies, adjacent organs i.e. ureter)

How to Avoid the Pitfalls Get complete information & understanding of the previous procedure Plan surgical strategy: Port sites position, complete Lap, Lap assisted, hand assisted

How to Avoid the Pitfalls Positioning: both arms tucked in, Lithotomy - team positioning flexibility Room setup: 2 TV monitors!

How to Avoid the Pitfalls (Technical Considerations) Open technique for insufflation First port placement away from scars (a-traumatic Trocars / Visual ports) Finger adhesiolysis (to create initial work space) Angled scope – only! A-traumatic intestinal graspers & dissectors

How to Avoid the Pitfalls (Technical Considerations) Adhesiolysis and additional port placement Reestablish / confirm Anatomy Identify pathology (tattoo in CRC, IOUS for solid organs) Urethral stents (depending procedure) HALS? Sound judgment & low threshold for conversion

Re-operative Laparoscopic Colorectal Surgery Our Experience 1443 Lap. Colorectal procedures Oct. 2002 - Oct. 2010 42 Reop (2.8%) : 31 IBD (27 Rec Crohn’s, 4 UC) 7 Rec. CRC 4 Benign disease 26M, 16F, 21-79y old 1-13y - time from last procedure

Re-operative Laparoscopic Colorectal Surgery Our Experience 37 prev. open procedure (5 pts. 2-4) 5 prev. lap. procedure Procedures: Ileocolic resection 22 Small bowel resection 11 Strictureplasty 5 Segmental colectomy 9 Comp. proctectomy IAP 4

Re-operative Laparoscopic Colorectal Surgery Our Experience Results: Conversion rate 12% (n=6) exposure & adhesions - 5 bleeding - 1 Morbidity 19% (n=8): prolonged ileus - 6 post op intestinal bleeding - 2 (1 relaparotomy) LOS mean 9 (6-21) days

The Role of Re-operative Laparoscopic Surgery Literature Review

Re-operative Laparoscopic Surgery Anti reflux Colorectal (IBD mostly Crohn’s disease, CRC) Morbid obesity SBO (adhesion related)

Re-operative Laparoscopic Surgery For Crohn’s Disease 70 – ileocolic resection 28/70 – previous ileocolic resection 1 – conversion ( in redo group) 7- complications (leak, stricture, hemorrhage, PE, SBO, line sepsis, UTI) all in primary group Canin J, Salky B, Edye M 1999 Surg Endosc

Re-operative Laparoscopic Surgery For Crohn’s Disease Conclusion: Experience required for successful laparoscopic management in complicated Crohn’s Canin J, Salky B, Edye M 1999 Surg Endosc

Re-operative Laparoscopic Resection for Crohn’s Disease 23 patients underwent laparoscopic reoperation for recurrent Crohn’s. Conversion rate - 69% (n=16( Complication, length of operation were the same Uchikoshi et al, Surg Endosc October 2004

Laparoscopic Assisted Ileocolic Resection for Crohn’s Disease 168 laparoscopic-assisted ileocolic resections. 78.4% (n=124) redo Previous resection was not a predictor of conversion to laparotomy Edden Y. et al. JSLS 2008

Laparotomy vs. Laparoscopy? Major Complication post Laparoscopic Surgery Requiring Re-Exploration Laparotomy vs. Laparoscopy?

Is a Laparoscopic Approach Useful for Treating Complication After Primary Laparoscopic Colorectal Surgery? 510 patients 5.2% reoperation (n=27) 65% anastomotic leak (n=15) Lap. approach 17 pts. (13/17 anast leak) Open approach 10 pts. (2/10 anast leak) Rotholz NA, Laporte M, et al. Dis Colon Rect 2009

Is a Laparoscopic Approach Useful for Treating Complication After Primary Laparoscopic Colorectal Surgery? Results: LOS 12d vs. 18d (P=NS) Complications 1/17 vs. 3/10 (P=NS) Rotholz NA, Laporte M, et al. Dis Colon Rect 2009

Reoperation Following Minimally Invasive Surgery: Are the ‘Rules’ Different? Trocar sites are the most common cause of bowel obstruction in the early post operative period McCormick JT.& Simmang CL. Clin Colon Rectal Surg 2006

Concluding Comments Results comparable/similar to primary laparoscopic resection Late in the learning curve, experienced team Patients selection

Concluding Comments Expect higher conversion and longer OR time Surgeon’s sound judgment to ensure patients safety

LAP HAND ASSISTED RIGHT COLECTOMY

SURGICAL INSTRUMENTS AND EQUIPMENT Angled scope Intestinal Graspers & Dissectors Tissue and Vascular division: Harmonic Scalpel (LCS) Ligasure Endo Staplers Endoclips

Lap assisted ileocolic resection in Crohn’s dis.: are phlegmons, abscess or recurrent disease a contraindication? 46 pts. lap Group 1 : 14 inlam mass Group 2 : 10 recurrence after prev resection Group 3 : 22 none of above Group 4 :70 pts. Open Conclusion: inlam mass, prev resection – not contraindication Gr 4 Gr 3 Gr 2 Gr 1 245 cc 195 cc 131 cc 151 cc blood loss 21% 15% 10% 0% morbidity 2 1 conversion Wu J, Fleshman J, 1997 Surgery

LAPAROSCOPIC SURGERY FOR RECURRENT CROHN’S DIS. 61 laparoscopic procedures,26.2% (n=16) redo No differences in the rate of postoperative complications Hasegawa H. et al. Br J Surg 2003